CA Fines 10 Hospitals $625,000 for Medical Errors

4. At California Pacific Medical Center, St. Luke's Campus, San Francisco, an attempt to treat a patient undergoing emergent dialysis resulted in providers neglecting to remove a catheter guide wire that had been inserted in the right femoral vein, but had migrated to his right ventricle.

But after the patient developed critical symptoms and was moved to the ICU, "it was noted that he was very tachypneic (rapid breathing), had altered mental status, had bradycardic arrest (arrhythmia or abnormally slow heart beat less than 50 beats per minute) short CPR, apparently difficult intubation.

A chest x-ray post intubation "noted that he had something that looked like a guide wire at the level of his right ventricle," where it "could have traveled in the direction of blood flow from femoral vein."

The patient had to undergo a second procedure to retrieve the guide wire from the vena cava.

Subsequently, the physician who had placed the guidewire told investigators that he "wasn't familiar" with that particular cath kit, and "I thought I knew how to use it."

Penalty: $50,000. This is the hospital's first penalty.

5. At UCLA Medical Center and Orthopaedic Hospital, Santa Monica, in Los Angeles County, surgeons neglected to remove a sponge from a patient who had to undergo a second surgery to remove it.

State investigators said that in having to undergo another procedure with anesthesia, the patient "was placed at risk for possible additional complications (i.e. bleeding, infection, shock, adhesions, ileus (paralysis of the bowel), changes in blood pressure, heart rate or heart rhythm and allergic reaction to general anesthetic medicine."

Penalty: $50,000. This is the hospital's first penalty.

Falls

6. At Tri-City Medical Center, Oceanside, San Diego County, providers failed to follow procedures prevent a patient known to be at risk of falls from falling out of his geri/bed chair in the hallway where he waited for a radiology scan.

He suffered a blunt force injury of his torso, rib fractures, and a hemoperitoneum (blood in is peritoneal cavity and hemorrhage, which led to his death hours later.

State investigators said that while most geri/bed chairs are equipped with a strap to prevent falls, this one did not.